Difficult Abdominal Wall Closure: Component Separation versus Partition
Technique
Pin-Keng Shih, M.D.1,2
1Department
of Plastic and Reconstructive Surgery, China Medical University
Hospital, Taichung, Taiwan
2China
Medical University, Taichung, Taiwan
Correspond to:
Pin-Keng Shih, M.D.
Department of Plastic and Reconstructive Surgery, China Medical University
Hospital, Taichung, Taiwan
2 Yuh Der Road, Taichung City, 404, Taiwan
Tel.: (886)-4-22052121 ext. 1638; Fax: (886)-4-22029083
E-mail: pinkeng.shih@gmail.com
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Short title: component separation versus partition technique
Key Words: abdominal wall repair, component separation, partition technique
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Abstract
Background: Partition technique and component separation techniques are natural
methods of fascia-fascia closure. We present our experiences and research the
differences between the two techniques.
Methods: From January 2006 to August 2013, 41 patients with complex abdominal
wall defects reconstructed with partition or component separation technique alone
were enrolled into this study. The related data including gender, age, size of defect,
operation time, hospital stay, duration of follow-up, comorbidities, body mass index
(BMI) and complications were collected. Nonparametric Mann-Whitney test was used
to evaluate the differences between the two groups in continuous data; chi-square test
was used to assess the categorical data.
Results: The mean defect size of patients with partition technique was 12.55 cm
(range, 8.2 to 18.9cm) with 148.63 minutes for average operation time, 8.66 days for
hospital stay, and 28.8 months for mean follow-up. There were nine cases with
postoperative complications (three cases with skin and soft tissue necrosis; two cases
with fascia dehiscence; and three cases with wound infection). One case with fascia
dehiscence suffered from pneumonia simultaneously. Four cases received secondary
operation (fascia repair and split-thickness skin graft), and the other four cases healed
spontaneously with mild wound debridement. The mean defect size of the patients
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with component separation technique was 9.45 cm (range, 5.7 to 12.6cm) with 143.27
minutes for average operation time, 7.43 days for hospital stay, and 34.33 months for
mean follow-up. One case with skin and soft tissue necrosis underwent reconstruction
with split-thickness skin graft and debridement. Two cases with wound infection
healed spontaneously with mild wound debridement. There were no significant
differences in gender, age, operation time, hospital stay, duration of follow-up,
comorbidities, body mass index (BMI) and long-term postoperative complications
between the two groups, except for size of defect and short-term postoperative
complications.
Conclusions: The partition technique could close larger abdominal fascia defects than
component separation technique but simultaneously run the higher opportunities for
short-term postoperative complications.
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Introduction
Difficult abdominal wall closure is a large challenge especially for all surgeons.
Delayed abdominal wall closure may cause wound infection, bowel ischemia, ileus,
ventral herniation and cosmetic dysfunction. Different methods including split
thickness skin graft [1], local or free flap transfer [2, 3], silicon mesh [4] have been
reported. Component separation technique was considered a natural method of
fascia-fascia closure without complications of artificial implant due to creation of
linea alba, successfully providing a midline anchor. However, components separation
is indicated only when the upper limit of the defect is 6 cm in the subxiphoid area, 10
cm at the waist, and 5 cm in the suprapubic region respectively on each side [5].
Partition technique was another method considered to close abdominal fascia defect
naturally [6, 7]. In addition to the advantages of component separation technique,
partition technique was suggested to more elastic space for primary closure than the
other due to more muscle tension release (external oblique and transversalis
abdominalis muscle vs. external oblique muscle only). However, published details of
any comparative method concerning the outcomes of component separation and
partition technique are still lacking. In this study, we have analyzed the follow-up of
our initial experiences of partition technique in comparison to component separation
technique, and we have also evaluated which operation is the best choice for difficult
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abdominal wall closure.
Patients and methods
This was a retrospective review at a single medical center between January 2006
and August 2013. Of 67 patients operated for complex abdominal fascia closure, 18
patients were treated by partition technique and 23 patients by component separation
technique only. This study included some patients mentioned in previous papers.[8]
Mean age at operation was 48.6 years (range 17 to 79 y) and mean body weight index
was 25.3 kg/m2 (range 18.7 to 29.3). Most of the component separation technique was
performed by traumatic surgeons and the partition technique was performed by plastic
surgeons. All the patients signed the informed consent.
The fascia defect was defined as the maximum distance between bilateral rectus
abdominis sheath on abdomen computed tomography (CT) before operation and
recorded as fascia defect width. Reasons of difficult abdominal wall closure included
wound dehiscence after repetitive operation, and acute abdomen or blunt abdominal
trauma. Twelve of forty-one patients were smokers; fourteen were diabetic.
Surgical technique
Partition technique
The technique has been described in detail in Lindsey’s study [6]. Briefly, the
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subcutaneous layer was dissected from the margin of fascia defect to anterior axillary
lines bilaterally. Parallel, parasagittal, staggered releases of the transversalis fascia,
transversalis muscle, external oblique fascia, external oblique muscle, and rectus
fascia from the costal margin to the pelvic inlet. Fascia-to-fascia closure was
performed in the midline by PDS 1-0.(Figure 1) Two Jackson-Pratt drains were
routinely placed underneath the subcutaneous skin flaps and allowed to remain in that
location until drainage was less than 20 cc in a 24-hour period, at which time the
drains were removed.
Component technique
The technique has been described in detail in Ramirez’s study [5]. Briefly, The
subcutaneous tissue and fat were initially separated from the abdominal wall,
followed by external oblique muscle being transected about 2 cm from the rectus
abdominis sheath. The external oblique muscle was dissected from the underlying
internal oblique muscle as laterally as possible. Fascia-to-fascia closure was
performed in the midline by PDS 1-0.(Figure 2) Two Jackson-Pratt drains were
routinely placed underneath the subcutaneous skin flaps and allowed to remain in that
location until drainage was less than 20 cc in a 24-hour period, at which time the
drains were removed.
Data collection
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The age, body mass index (BMI), size of fascia defect, operative time, hospital stay,
comorbidities, follow-up and postoperative complications of each patient were
collected for statistical analysis.
Statistical Analysis
The parameters were not normally distributed. Since the sample sizes between the
two groups were also different, the nonparametric Mann-Whitney test was used to
determine the magnitudes of between-group differences. Chi-square was used for
determining differences between the two groups in postoperative complications and
comorbidities. Values of p < 0.05 were considered statistically significant. Graphpad
for Windows version 5.0 was used for all statistics.
Results
Partition technique
The study group included 12 males and 6 females with a mean age of 47.3 years
(range: 17–71 years). All patients had partition technique reconstruction had resulting
from severe trauma (14 cases), bowel perforation (3 cases), and cervical cancer with
wide excision (1 case). Operative time averaged 148.63 min (range: 80–277 min). The
hospital duration was 8.66 days (range: 3–15 days), and the mean follow-up was 28.8
months (range: 13~49 months). In short-term follow-up, nine cases had postoperative
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complications, and there were three cases with skin and soft tissue necrosis, two cases
with fascia dehiscence (one case with minor ventral herniation (1 cm), and the other
with lower abdomen fascia dehiscence), and three cases with wound infection. The
patient with skin and soft tissue necrosis underwent debridement and split-thickness
skin graft. The cases with ventral herniation (1 cm) and wound infection received
stitch removal and wound with wet gauze filling, and then all cases healed
spontaneously without secondary operation. The case with lower abdomen fascia
dehiscence suffered from pneumonia simultaneously. The patient received secondary
operation for fascia repair and antibiotics for pneumonia. In middle-term follow-up,
none of the patients developed abdominal complications.
Component technique
There were 19 males and 4 females with a mean age of 52.3 years (range: 21–79
years) in this study group. The patients with component technique reconstruction
composed of severe trauma (17 cases), bowel perforation (2 cases), and ventral
herniation (1 case) and ischemic bowel (3 cases). Operative time averaged 143.27 min
(range: 60–233 min) with 7.43 days for average hospital stay, and 34.33 months for
mean follow-up. In short-term follow-up, one case had complications with skin and
soft tissue necrosis and received secondary operation for debridement and STSG. The
two cases with wound infection received stitch removal and wound with wet gauze
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filling, and all wounds healed spontaneously without secondary operation. At
mid-term follow-up, none of the patients developed abdominal complications.
Comparison of the two groups
There were no significant differences in age, BMI, operation time, hospital stay,
follow-up, long-term postoperative complications between the two groups. There
were significant difference in abdominal fascia defect size (12.55 vs. 9.45, p<0.05)
and short-term postoperative complications (9 vs. 3, p<0.05). (Table 1,2)
Discussion
Component separation technique was presented in 1990 by Ramirez et al. for
abdominal wall reconstruction [5]. The external oblique muscle release allows for
medial advancement of the fascia and closure of up to 20-cm wide defects in the
midline area. Compared with component separation technique, the partition technique
for abdominal wall closure is less reported. The partition technique focuses on
parallel, parasagittal, staggered releases of transversalis abdominalis and external
oblique muscle. According to Lindsey's report, all the fascia defect sizes closed by the
partition technique are larger than 20 cm.[6] After reviewing the related studies, the
both techniques supply good outcomes for abdominal wall closure. In fact, with the
intervention of mesh, fewer and fewer cases use component separation or partition
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technique alone for difficult abdominal wall closure. In this study, we attempted to
demonstrate the values of both techniques.
The results showed the fascia defect size closure by either partition or component
separation technique is much less than that in the Ramirez or Lindsey's report. The
difference depended on the various methods to measure the fascia defect size. Both
Ramirez and Lindsey measure the fascia defect size intraoperatively after complete
enterolysis and soft tissue dissection, but we used the preoperatively maximal gap
between bilateral rectus abdominalis in abdominal CT as the fascia defect size. In
contrast, the fascia defect size in our report is less than that reported in previous
studies.
In this report, the results suggested the fascia defect size closed by component
separation technique (9.45 cm in average) is significantly less than that of the partition
technique (12.55 cm in average). In theory, the partition technique could close larger
fascia defect sizes than the component separation technique due to more elastic space
and tension release (external oblique and transverse abdominalis muscle versus
external oblique). No difference in operative time between the two techniques means
that it did not take too much time for an experienced surgeon while dissecting one
more muscle layer. On the other hand, the partition technique has another advantage
over the component separation technique: more space for cases with enterostomy. It is
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difficult to dissect the external oblique muscle from cases with enterostomy by
component separation technique, and the parasagittal release of external oblique and
transverse abdominalis muscle partition technique left space for the enterostomy.
In this case series with the partition technique, nine of eighteen cases suffered
from complications (three cases with skin and soft tissue necrosis; two cases with
fascia dehiscence; three cases with wound infection). The complication rate is smaller
in this report (50 %) than that of Lindsey's (60 %). The average fascia defect size in
the 9 cases with complications was 15.23 cm compared with 10.37 cm in the 9 cases
without complications (data not shown). With the low cases with comorbidities and
normal range of BMI index, the above finding may indicate that the abdominal wall in
the cases with complications suffered from higher fascia-fascia tension than the cases
without complications. In the mid-term follow-up, although no cases suffered from
abdominal wall weakness and fascia re-herniation, parasagittal release of both
external oblique and transverse abdominalis muscle may run the risk of abdominal
wall weakness.
In the patients with component separation technique, 3 of 23 cases suffered from
postoperative complications. Compared with other studies, the complication rate in
this report was relatively smaller.[9, 10] The major causes were attributed to smaller
abdominal fascia defect (smaller tension for fascia-fascia closure) and lower BMI
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index (25.0% in average versus others). Although tobacco smoking and diabetes
mellitus are major preoperative risk factors for postoperative complications [11], the
higher case number (compared to the groups with partition technique) seemed to have
no direct effects on the complications in this study.
Compared with the component separation technique, the partition technique could
close larger abdominal fascia defects but simultaneously run the higher opportunities
for short-term postoperative complications. There was little difference in the mean
abdominal fascia defects between the groups with component separation technique
(9.45 cm) and the cases without postoperative complications by partition technique
(10.37 cm), which may imply that there is no difference in postoperative
complications between the component separation and partition techniques if the
abdominal fascia defect is less than 10 cm. Even in the higher postoperative
complication rates with the groups by partition technique, adequate salvage makes up
similar long-term outcomes as the group with component separation technique.
Although there were more cases with comorbidities in the group with component
separation technique, the outcome showed the comorbidities are not closely related to
postoperative complications.
In fact, with the use of mesh, the complications induced by fascia-fascia closure
tension dramatically decreased and the board line of abdominal fascia defect between
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two techniques became obscure. The cases reconstructed by either component
separation or partition technique alone became more and more important.
However, there are some limits in this study: Firstly, only a few cases were enrolled
in both groups, and the procedures were performed at a single facility and may not be
reflective of all institutions. Secondly, the shortness of the follow-up period left us to
make conclusions about only a few complications of both techniques. Because this is
a retrospective study, more long-term follow-up is necessary.
In conclusion, the partition technique could close larger abdominal fascia defects
than component separation technique but simultaneously run the higher opportunities
for short-term postoperative complications.
Acknowledgements
The study received assistance from Dr. Hsin-Han Chen for the work being
published.
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Figure Legends
Figure 1. The representative picture of fascia-fascia closure by the partition technique.
Figure 2. The representative picture of fascia-fascia closure by the component
separation technique.
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